TMHU LIFE SAFETY LIVE SKILLS CERTIFICATION APPLICATION First Name: Last Name: Colleague #: Unit: Work e-mail: Telephone: I acknowledge that I am responsible for maintaining current certifications as part of my employment at TMH. I acknowledge that if I fail to do so, I am subject to being turned off in Payroll and face possible disciplinary action (Initial here) Instructions: Complete this application by placing a check mark in the appropriate section (s). You MUST SIGN both the application and payroll deduction portions of the form in order for this application to be processed. Once both sections of this form have been completed and signed, either scan or email to: DAINA.JORDAN@TMH.ORG OR FAX TO EXT. 6599 for processing. Select the requested class below: TMHU LIVE ACLS Initial (2 day) TMHU LIVE PALS Initial (2 day) TMHU LIVE PALS Renewal TMHU LIVE BLS Renewal TMHU LIVE ACLS Renewal cost: $100.00 cost: $125.00 cost: $100.00 cost: $20.00 cost: $75.00 Initial below: I understand that the cost of the course will be deducted through payroll from my check if: If I submit this form and do not attend. If I cancel this class without 24 hour notice. PAYROLL DEDUCTION FORM I AUTHORIZE TMHU to deduct the below listed amount of my pay if I fail to complete the Life Safety Class listed above or cancel within the 24 hour window. These funds will be deposited into 6014-63900. Class: Deduct amount: Deduct code: 3279 Date of Class: Colleague signature __________________________________________________ Date _________________________ This form will only be processed if you fail to fail to attend a TMHU LIVE Life Safety class that you have registered for. * Application must be completed in full to be processed.